UK EM Field Notes #8
My take on sepsis, circulation management in septic shock, peripheral noradrenaline
What is sepsis? (I think people get it wrong all the time)
I frequently ask residents what they think sepsis is. Quite often, they struggle to give a clear, confident answer. Sepsis is one of the most commonly encountered clinical syndromes in the ED, yet it remains surprisingly challenging to pin down exactly what it is.
I think that’s largely due to the ever-changing formal definitions and the shifting landscape of preferred scoring systems over the years - SIRS, qSOFA, Red Flag Sepsis, and so on.
This is how I explain sepsis when I am teaching:
Infection = local process, systemic response. Well patient.
Sepsis = infection + organ dysfunction. Unwell patient.
Septic shock = sepsis + cardiovascular collapse. Critically unwell patient.
An infection will often induce a high fever and raging tachycardia - fairly dramatic observations with high NEWS2 score (meeting “Red Flag Sepsis” criteria etc). But the patient is well. There is a systemic response, but no organ dysfunction. Viral URTIs spring to mind.
Real sepsis can be subtle and insidious. It can be easy to miss - particularly in the frail with an unclear baseline. The 89 year old with a UTI, normal observations, unexciting acid/base, negative inflammatory markers, and hypoactive delirium… is septic. Infection (UTI) + brain failure = sepsis.
Septic shock is a bit more obvious in most patients. However, that same 89-year-old might be normotensive and therefore not “NEWSing”, but is actually relatively hypotensive, as she runs hypertensive when normal. In that context, she would be in septic shock.
The simplicity of the “sepsis” concept is helpful in the ED
It’s pretty nuts that so many different pathogens - with entirely different pathophysiological processes and, therefore, a wide range of ED presentations - can all be funnelled into the same categorisation system. I’ve heard plenty of very clever people push back against that, which I understand.
However, I’m drawn to the simplicity of the “sepsis” concept.
When a process feels simple, it’s easier to do the job well - especially if the situation is time critical, like when managing a patient in septic shock.
I like knowing exactly what my game plan is, sense-checking my decisions by deliberately referring to local guidelines (which, for sepsis, is an excellent one-pager in my department), and then striving to deliver a measurably high standard of care (e.g. completing the Sepsis 6 within an hour of ED arrival).
Unpacking personal or team performance - and assessing how you’ve measured up in the pursuit of professional development - is much easier when clear guidelines and operational targets exist, as they do in sepsis management.
Management of the circulation in sepsis
Clearly this is a massive topic (which is mostly outside the scope of this short blog post). Here are a few of my take-aways from recent cases/discussions in the ED:
In general, we should probably be more aggressive in managing the circulation in sepsis, particularly in terms of starting vasopressors. Don’t wait until 3L have gone in before considering noradrenaline. Do it early.
Point-of-care echo is useful in guiding choice of vasoactive medication. As ever, keep it simple:
If there is a hyperdynamic heart (most often the case in septic shock), start a noradrenaline infusion.
If there is clearly poor LV function give adrenaline (initially small boluses → convert to infusion).
I think if you’ve poured in more than 500ml stat and the MAP is still low - just crack on. Start a peripheral noradrenaline infusion (see below). You can always stop it if you overshoot.
Despite how much good literature/education there is around the ED management of sepsis, I still feel - anecdotally - we’re too slow to start vasopressors. We must be bolder.
Peripheral noradrenaline
Noradrenaline can be started peripherally through a green cannula if it is well secured, ideally away from joint creases. This is well supported by the literature.
I think we should be initiating peripheral noradrenaline infusions much more often in the ED.
Giving metaraminol boluses before starting noradrenaline is common practice and acceptable as a short-term bridge. Noradrenaline is the first line vasopressor – don’t wait for a CVC to start it.
Here is a very comprehensive, up-to-date “EM Cases” blog/podcast on all things sepsis/septic shock.
Cheers all,
Robbie
@robbielloyd.bsky.social